How healthy are healthcare settings for transgender people?

The transgender, 'hijra' or 'kinnar' community is visible as usually its members can be spotted easily by way of their attire and mannerisms. However they are invisible in the sense that society shuns them and does not even want to acknowledge their existence. They face problems in all spheres of life. But, the impediments they face in accessing quality healthcare services at times, cause irreparable physical and mental damage to them and may even be life threatening.

Members of this forsaken community, along with civil society activists, recently met at a National consultation, aptly called Hijra Habba (festival), held in Delhi, to voice their legitimate concerns and seek solutions to their problems from the stakeholders and government officials present there. They had innumerable instances cite about the hardships they face even in getting the minimal amount of medical attention, leave alone any proper counseling worth the name.

According to Ernest Noronha from the United Nations Development Programme (UNDP) India, “The hijras face a two pronged problem within healthcare settings - one is the element of fear and the other is lack of knowledge. Even within the medical fraternity there are a lot of misconceptions/misgivings about them - are they born without some organs; do they have female organs; do they not have sexual organs? The examining doctor may not know what sexual organs the transgender (TG) has and is not prepared for the shock he might get (I am not even talking of the nurses and other staffs at that level because there is still more discrimination at that level). I strongly feel that the medical curriculum should have adequate information on sexual and health issues. Many transgenders suffer from mental health problems like depression and suicidal tendencies. So the doctor must understand what drives them towards such a state of despondency. They do not have anything to fall back upon apart from some community structure. If you are excluded from your family and are living in a pseudo family, if you do not have children, then what is there for you to look forward to, beyond your earning age of 40 years? So healthcare professionals need to be more sensitized; communities need to be proactive; parents need to understand and the government has to be serious in its efforts.”

Zeenat Pasha, a prominent Hijra guru from Mumbai and a founder member of the Dai Welfare Society, the first community-based organization of Hijras in India, has been working with people living with HIV in the Kamathipura (red light) area of Mumbai for the past 17 years. She is very vocal about the problems faced by transgenders who are HIV positive, and rues that, “The government programs are limited to distribution of condoms and at the best admitting a patient in a hospital in case of serious sickness. When hijras go to a hospital to seek treatment the first dilemma of the doctor is whether to admit them in male ward or female ward. If the hijra is nirvana (they have got themselves emasculated) he is sent to female ward. If he is not emasculated they are put in male ward. Seeing the devastation and death caused by HIV/AIDS hijras are becoming more aware and are counseling each other to save themselves from HIV related death. Earlier they had no knowledge about the benefits of condoms and about clean injection syringes. But now they ensure that the doctor is using clean syringes; else they do not go to him. But only 30-35% hijras have become more aware. So a lot more still needs to be done.”

Billy Stewart, Senior Health and AIDS Adviser at Department For International Development (DFID), UK, also agrees that: “there is clearly a set of challenges about the transgender and hijra community to access a lot many services, including health services. In India the counseling component is fairly weak across the board in health services, especially regarding mental health issues. This is one of the challenges for the country to develop community based interventions to deal with mental health requirement and counseling requirements of transgenders/hijras. The quality of health care services and Sex Reassignment Surgery (SRS) services also needs to improve and become more responsive. Of course the community will have to be engaged more for this. We need more articulate community members to come forward.”

James Robertson, Country Director of India HIV/AIDS Alliance informs that according to the best estimates available, the number of transgenders in India is 750,000 and the high prevalence of HIV incidence in the community ( it is 30 to 60 times higher than in general population) poses a serious challenge to address their health. He cites the case of a patient who was turned out from a West Bengal hospital even though she was suffering from sepsis after having undergone Sex Reassignment Surgery (SRS). It was after a lot of advocacy at civil society level and community led protests that finally they could find a hospital and doctor who could provide the care that she needed. James laments that, “Such incidences should never happen and yet they are very common. We have a very long way to go. All of us have to become more sensitive towards them. There should be more sensitization programmes for doctors, health workers, government officials, policy makers. There should not only be sensitization but an understanding of the TG issue must be part of the medical training which doctors, nurses and healthcare professionals undergo.”

Mujra is a Hijra activist from Mumbai who runs a support group for Hijras living with HIV from her home and attends to those in need. She also provides quality peer counseling and yoga training to meet mental health needs of the TG and Hijra community who are also infected with HIV. She is very vocal about the problems which the hijra community faces in accessing treatment and healthcare services: “For them just to get tested for HIV/AIDS is a big issue. They do not get motivated easily to go for testing. They have to be counseled a lot that being HIV positive is not the end of life and that they can still live normally by taking medicines. Even when we convince the person to see a doctor, then we face many problems at the time of registration for which some identification and address proof is required, and in the absence of these documents registration cannot be done. All hijras do not possess such a proof. Similar problems occur at DOTS (Directly Observed Treatment Shortcourse) centre, where residential address of the patient is a compulsory requirement for registration. This is a big problem and I request the government to find a way out, as hijras are also a part of society. Again, even if the doctor at the health centre says yes for admission, when they go to the ward then the nurses and other staff reveal their identity and also wonder where they should keep the hijra. Then, other patients in the ward also start discriminating.”

“There is virtually no counseling worth the while available at government level. The patient is just told when he/she has to eat the medicines, and what nourishing diet is to be taken. But there is no quality counseling to equip the patient to cope with the disease and the mental stress and other psychological problems arising out of it. I try to counsel them on many aspects - mental, medicinal, etc. Here I would like to stress the importance of yoga in the treatment of HIV. I have helped many patients to not start on antiretroviral (ARV) treatment just by making them do yoga regularly. I think more community participation is needed to lessen our misery. Along with proper healthcare facilities we also need some income generation activity for hijras.”

This meet was organized by Pehchan project in association with India HIV/AIDS Alliance.

Shobha Shukla is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. http://www.citizen-news.org

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